ML20155F766

Partially Deleted Job Number 739619-96, Investigation of E Diesel Breaker Misalignment

ML20155F766
Person / Time
Site:	Susquehanna
Issue date:	07/25/1996
From:	Brinckman C, Duda D, Urban M PENNSYLVANIA POWER & LIGHT CO.
To:
Shared Package
ML20155F723	List: ML20155F720 ML20155F749 ML20155F766 ML20155F774
References
FOIA-98-81 739619-96, NUDOCS 9811060110
Download: ML20155F766 (8)

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mv.gyl n~ ~ l July 25,1996 Corporate Audit Services (Auditing) conducted a review of the June 14,1996 at the Susquehanna Steam Electric Station (SSES)(. circum The primary objective of our review was to inde )endently evaluate the possibility of tam xring as it relates to the failure to discover t le Misahanment in a the wrong breaker while erforming a routine job function which r)esul Misalignment. During period between June 14 and July 4,1996, three surveillances conducted by 3 different POs failed to discover the Misalignment. Our review centered upon the rehability of these three surveillances and the possibility that the Misalignment could have been purposely concealed. A Plant Event Review Team (ERT) and Independent Safety Evaluation Services (ISES) are each conducting reviews of the event. EXECUTIVE

SUMMARY

In our opini it is unlikely that the Misalignment was el concealed f l or that someone tampered)th the E Diesel breaker between June 1[an fulf 4,1996. in the absence of collusion, an individual would have had to purposely correct the h Misalignmentjus ri r to a June 20 surveillance and then re set it in the improper position after a eillance was complete. We found no evidence to.suggest. these circumstances. We.believe that human error, NPOs, is the. reason the Misalignment remam,in particular inattentiveness to de ed undetected from June 14 until July 4, 1996. We base this conclusion upon the following facts: One NPO admitted that his surveillance results may not have been e accurate. There is also evidence which suggests that he conducted his surveillance too quickly to be effective. had past perform, whom we were unable to interview during our re A second NPO ance >roblems associated with inattentiveness to detail and performing sis work too quickly. . A third NPO admitted he did make a mistake while performing his surveillance of the T Diesel. The NPO observed signs of a problem with the T Diesel breaker but after assessing the situation, he ' convinced himself that no problem existed. Subsequently, the NPO realized be made an error mjudgment. .. NPOs expressed concern about the confusing format (ical surveillanc in particular the ence of steps to be performed) of the diesel electr (S 100 005 procedure used as a guide to perform the surveillance and for docum)entation of results. Nuclear Operations does not require periodic supervisory participation for the inspection process of the diesels. This control is utilized m many other similar inspections throughout SSES. NPOs indicated they were ' comfortable' with the diesel electrical surveillances and did not expect to find any problems. EX B1T i PAGE _0F1PAGE(S)

a 2- 'It may be appropriate to review the applicable procedures and training to determine the extent, if any, to which they contributed to the NPOs' overall performance. Additional support for our opinion and details of Auditing's Action Plan follows. I BACKGROUND Highlights of the Misalignment events are as follows: On June 14,19%, NPO #1 was assi; ped to perform a swap of the e T Diesel for the 'D' Diesel. When t2e Misalignment was discovered and shown to NPO #1 he realized and agreed that he had moved the wrong breaker, thu,s resulting in a uusalignment of the' Diesel, e On B, NPO #2 merformed a scheduled electrical 'surve ance o te T Diesel and did not discover any alignment NPO #3 wrformed a scheduled electrical e surveillance of the T Diese: and did not discover any alignment problems. , NPO #4 performed a scheduled round which has suspected a problem with the T Die)sel breake e a he did not have time to investigate the problem that night. On NPO #5 performed a scheduled electrical i s ance o e T Diesel and observed signs of a problem with the T Diesel breaker. However, after assessmg the situation, he convinced himself that no problem existed. , NPO #4 performed a scheduled round in the T Di an upon closer inspection of the T Diesel breakers, discovered the Misalignment. Initial interviews with NPO #2 and #3 ebnducted by the ERT Team (which was formedon Jul 5,d the ) breakers were properly ali ped. Inconsistencies betweer the 1996 indicated that these NPOs believed their surveillances were properly an results o surveillances and the subsequent rount perfonned by NPO #4 raised the possibility of tampering. ACTION PLAN In performing our investigation, Auditing took th'e following actions: l met with the ERT Team to obtain background information l reviewed associated condition reports evaluated overtness, intent, and sophistication of this inc_ident EXLEIT v -. -

w,,w., l : collected and reviewed othe'r relevant documentation including: surveillance reports, plant logs, performance evaluations and trauung recorcfs conducted a walkdown of the T Dicsel building observed a mock surveillance /round of the T Diesel building identified individuals who were directly related to events occurring i from the time the Misalignment occurred until discovered and corrected interviewed employees directly related to the Misalignment interviewed other employees who were in the T Diesel building during the Misalignment period reviewed wor'; authorizations associated with equipment #0A510 (T Diesel breaker panel) reviewed labeling changes on the OA510,T Diesel breaker panel Evaluation of Tampering as a Root Cause 7 3,. We believe the possibility of tampering is unlikely based on the following w . NPO #1 admitted to making the mistake which resulted in the Misalignment on June 14,1996. . NPO 42 admitted that his surveillance results may not have been accurate. . NPO #5 admitted to observing a problem with the breaker alignment. e In the absence of collusio an individual would have had to 'gnment purposely correct the Mi surveillance and then re-set it in the.just prior to a June 20 improper position after a June 27 sarveillance was complste. . We did not find'any evidence to indicate that anyone intentionally; performed any activity which would result in two of the three surveillances not discovering the Misaligmnent (i.e., intentionally correcting the error prior to the first and/or second surveillance and subsec uently re establishing the Misalignment prior to the third survellance), e The majority of NPOs interviewed told us they were not fully aware of the control room alarms associated with the T Diesel breakers or the consequences of making the breaker movement, and thus would not have been confident of their ability to correct the Mitalignment undetected. . During our interviews we found no evidence ofintent to cause harm (i.e., explicit or implicit threats of tampering). . During our interviews of personnel accessing the T Diesel building between June 14,1996 and Jul 4,1996, no one indicated observing or having knowledge of unusu activity within the T Diesel building. IX MT PAGE OF 7 PAGE(S)

i ' ' ~~ N"% . j Evaluation of Human Performance Factors as a Root Cause We believe that human error by NPOs is a more likel cause of the electrical surveillances not discovering the Misalignment based on the following: MURVEILLANCE PERFORMED BY NPO #2 Although NPO #2 initially claimed he did this surveillance accurately, he did admit to us that he "could have screwed u 2" (in regards to ' g the surveillance). Records indicate that his surveilance was comp d in 2 minutes and 11 seconds. Based upon our interview of knowle able SSES personnel and

grformance of a mock / test surveillance, we teame that it takes approximately 8, minutes o properly complete such a surveillance. NPO #2 also told us that once you net accustomed to the surveillance, y#2 also told us that he stood by cubicle ou really don't have to read each label in orde'r to complete the surveillance. NPO panel OA510 and looked down the row for indicator li ts his surveillance. He said he didn't "need hands on" ysically check th reaka indication on lights". An SSE ofinstruction trains NPOs)to p ou have proper sically check the i

breakers in order to verify they are racked-in. NPO #2 also told us t if ever gis normal as usual and in spec) he documents equipment status on his way to ano er location. We be leve that proper protocol would have an NPO document the equipment status concurrent with his observation, thus reducing the chance for error. NPO #2 did not pay attention to detail andBased on the above facts, we be Nb t did not conduct a t electrical surveil.ance of the T Diesel on M SURVEILLANCE PERFORMED BY NPO #3 7 We were unable to verify the reliability of NPO #3's surveillance (which was performed on night shift based on the fact that he was unavailable for us to interview. However we did rform attemative audit procedures that raise some questions about the r,eliabili of his surveillance report. We reviewed NPO #3's past performance evaluations an interviewed. supervisors. Despite the fact that his most recent rmance evaluation did not in ate any performance ems, we learned 4 that

1. 3 has had problems with inattentiveness to detail and wrformmg work too quickly in the recent past. In addition, NPO #3 was previ acedin the usible use a procedural c in hand, i

Behavior Program for a failure to supervisor commented that most o y#3's problems or errors occurred when he was working night shift. Altho NPO #3 did receive breaker training in February 1995 our review i of certain T Diesel sker trau' u'ng data indicated that NPO #3 did not receiv,e revised I OA510 breaker racking training in the 4th Quarter 1995. Based on the above facts in combination with the results of our interviews conduct an accurate surveillance.),We understand that Nuclear Operations interview this NPO prior to his return to duty. EX IT PAGE OF 8 PAGEIS)

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=. x, URVEILLANCE PERFORMED BY NPO #5 NPO # 'ted he made a mistake while performing his surveillance of l the 'E' Diesel on R Specifically, he stated that he did not open the OA51005 b l breaker panel to t the breaker was in the proper position. He also told us that he I had observed'.fignre hat he tho t could be a problem with that bre but after assessing the situation, he convince himself that no problem existed and h did not no the control room. This NPO was relatively inexperienced in performing this parti ular surveillance and told us that this was only the third time he had done it. He told us he had difficulty following the surveillance procedure and that this contributed to his mistake.. When questioned by a shift supervisor after the Misalignment was discovered, NPO #5 immediately realized he made an error in ' t during his surveillance. He stated that he concluded too quickly that no pro existed. He also stated that he did not see the instructions on the surveillance verify that the OA51005 breaker was in the proper position. procedure requiring h OTHER FACTORS In addition to the above information, we believe there are other factors indicating the existence of human performance problems associated with NPOs not paymg attention to detail. Certain reoccurring t2 emes surfaced during our interviews. These included: More experienced NPOs werFFnerally ' comfortable' with the 'E' Diesel surveillances and did not expect to find any problems. e ' UtIer NPOs expressed concern about the confusing format (in particular the sec uence of steps to be performed oTthe diesel electrical surveil:ance ocedure (SO.100-005)d for documentati h is used by NPOs as a guide to rm the surveillance an ofresults. Nuclear Operations does not require periodic supervisory parti,cipation for the inspection process of the diesels. This control is utihzed in many other similar inspections throughout SSES. ACKNOWLEDGMENT We wish to acknowledge the assistance that Nuclear Department personnel provided to us durms our review. If you need additional information or would like clarification on any items contained in this report, please feel free to contact us. l Corporate Audit Services g 'EX)ilBIT r PAGE W-OF S PAGEIS)

ED 1 conndential._ o August 16,1996 Mr. K. V. Chambliss: Re: Sunplement to Investigation of'E' Diesel Breaker Misalignment Report At the time Corporate Audit Services issued our report entitled " Investigation of'E' Diesel Breaker Misalignment"(dated July 25,1996 - Job

1. 739619 96), we were unable to interview one of the NPGs (NPO #3) who l

performed Surveillance and Rounds of the 'E' Diesel Generator Building. However, on July 29,1996, we interviewed NPO #3 to determine the circumstances surrounding hisWSurveillance and Rounds of the 'E' Diesel Generator Building in which he did not detect a breaker misalignment. Following are highlights of our interview with NPO #3: At the start of the interview, NPO #3 was confident that he had properly conducted the Surveillance & Rounds onM. However,later in the b (, interview he indicated that potential tampering or a mistake on his part (inspecting the wrong breaker) are two reasons why his Surveillance did not detect a breaker misalignment. In his opinion, each possibility had an equal probability of being the cause. Near the close of the interview, he indicated there was a 60-70% chance that he could have made a mistake by inspecting the wrong panel in conducting his Surveillance. A,lthough NPO #3 stated it typically takes him 10 - 15 minutes to do 9{ Surveillpce and Rounds of the 'E' Diesel Generator Building, security access data indicates he performed theMSurveillance and Rounds in approxi nately 5 minutes. t The results of this interview did not change our overall report con'clusion that it is unlikely that someone tampered with the 'E' Diesel breaker. We base this conclusion on the facts described in the aforementioned report. We believe that human error is the reason the misalignment remained undetected from June 14 O untii Juir 4,1996. EgBIT EB PAGE / OF1PAGE(S) l

OCT-21-95 MON 3:06 PM PFL NUC LICENSING F AX NO. 6107747540 F. 3 .~ Please note that on July 30,1996, Auditing informally cornmunicated the results of this interview to you. If you need additional information or would like clarification on the interview results, please feel free to contact me at ETN 220-4801. mmh. Martin F. Urban Corporate Audit Services cc: G. J. Kuczynski F. A. Long R. G. Byram

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